ACC: Improvements in quality metrics do not decrease patient mortality

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ATLANTA-Improvements in quality of care measurements do not decrease 30-day mortality rates, said Jersey Chen, MD, of the Yale University School of Medicine at the American College of Cardiology (ACC) scientific sessions March 15.

However, he discussed and evaluated how hospital strategy and quality metric implementation could improve 30-day all-cause mortality rates. For acute MI (AMI) and heart failure (HF), great differentiations occur in relation to the rates of risk-adjusted mortality. For AMI, Chen found that the best rates of AMI risk-adjusted mortality were 10.7 percent, while the worst were capped at 25.5 percent.

Chen evaluated how to alleviate these differentiations by looking at the best processes and quality indicators utilized in hospitals and how they affect mortality rates and improve overall care.

According to Chen, previous studies have shown that improved door-to-balloon (D2B) times have great variation--spanning from 50 minutes to 200 minutes. D2B alliance guidelines to lower D2B times to 90 minutes or less is a great improvement and is an important step toward improving quality of care.

Chen said that six strategies have been proven to improve D2B times:

  • Having an emergency department physician contact the cath lab;
  • Pre-hospital cath lab activation;
  • Early staff arrival at the cath lab by 20-30 minutes;
  • Utilizing a central data operator;
  • Having an attending onsite; and
  • Using real-time data.

Last year, Chen's colleagues at Yale examined how improved D2B times may effect all-cause mortality. The research found that while these improvements may have helped on an individual patient level, they showed little correlation to improve overall hospital mortality rates. “This is a disappointing finding,” he noted.

Chen said that the lack of improvement to mortality rates even with an improved D2B time could be because D2B times “are only one important factor” and studying other quality measures could help decrease mortality rates.

Additionally, Chen said that Yale researchers evaluated how the implementation of quality indicators can improve the use of beta blockers. Data from eight hospitals were evaluated to look at the disparities between “high performing hospital” versus others.

After evaluation, Chen said that when comparing the worst percentile and best percentile hospitals for composite scores of quality performance indicators and standardized mortality rates, all-cause mortality changed very little—1 to 2 percent.

According to Chen, even as systolic function measures and the use of pacemakers improve, 30-day mortality rates for these improvements “had absolutely no change.”

Chen offered that one reason that no correlation exists between quality indicators and morality rates may be because many patients could be excluded from quality indicator assessments due to being ineligible, having contraindications (allergies, etc.) and discretionary removal due to patient history. After breaking down the information, Chen found that only one-fourth of patients underwent analysis for quality indicators. Regarding this small cohort, researchers would "achieve good outcomes, but you don’t have any way to improve quality for the rest of the patients.”

Chen offered four goals that have proved to help decrease mortality rates at evaluated facilities:

  • Shared goals and agreement for excelling in cardiology care;
  • Focusing on problem solving;
  • Having strong communication among work groups; and
  • Using prompt real-time data feedback for performance targets.

Concluding, Chen said that facilities should encourage local solutions rather than adopting specific strategies at both the inpatient/outpatient levels to improve mortality. “There isn’t a lot of evidence about what we can do to reduce 30-day all-cause mortality, but I would suggest that hospitals optimize guideline-based care,” Chen concluded.